There is critical, nation-wide need to reduce the cost of health care while increasing access and quality. Electronic health records (EHR) and associated applications of health information technology (HIT) have great potential but it remains largely unrealized. EHR adoption faces resistance based on serious concerns, such as large start-up cost, unpredictable benefits, and disruption to clinical care work flow. Popular design paradigms for HIT focus on software features without making a clear, predictable connection to the way these features will achieve gains in efficiency and quality. Failure to make this essential connection can have the unfortunate side effect of changing workflow and decision making by accident rather than by design. In order to exploit the potential of HIT its designs must be based on an understanding of how care is actually performed, including an analysis of constraints and problem areas to prioritize how HIT should be applied to achieve measurable gains in efficiency and quality. We propose to model and analyze clinical care work flows, networks, and decision making at three sites, each representative of populations of interest to AHRQ: the VA Puget Sound Multiple Sclerosis Regional Program, the University of Washington Medicine Center for Pain Relief, and the Baylor Hospital Health Care Admissions Program. Our research team from the National Center for Cognitive Informatics and Decision Making has a long track record of working successfully together and with the Veterans Health Administration on the design of EHR, modeling of clinical care work flows, and improving healthcare decision making and the quality of care. Our research will leverage new software tools and techniques that were developed specifically for this purpose under funding from the Office of the National Coordinator for HIT (ONC). We will capture current workflows and methodically analyze how HIT can be applied to achieve measurable gains in the efficiency and quality in each area of clinical care. In addition, we will extract common design principles for workflows and HIT functions, publish our work flow models as a reusable library, and publish key HIT design artifacts, such as information dictionaries, information architectures, and user interface prototypes. Most importantly, we will demonstrate how an improved understanding of clinical work, task distribution and decision making, can methodically guide HIT design to increase care efficiency, reduce cost, and improve quality.